Skin Integrity
Anatomy and Physiology of the Integumentary System
Skin Layers and Structure: * Epidermis: The outermost layer of the skin. * Dermis: The middle layer containing nerve endings and blood vessels. * Hypodermis (Subcutaneous): The deepest layer, primarily composed of subcutaneous fat.
Key Components: * Hair: Structures growing from the epidermis. * Glands: Specialized structures within the dermis. * Sensory Receptors: Specialized cells for detecting environmental stimuli. * Touch Receptors: Specific receptors dedicated to tactile sensation.
Factors Contributing to Skin Breakdown
Chemical Factors: Exposure to substances that may irritate or damage tissue.
Developmental Factors: Age-related changes in skin thickness or elasticity.
Microbiological Factors: Presence of pathogens or bacteria.
Physical Factors: External forces such as pressure, friction, or shear.
Physiological Factors: Internal body processes affecting skin health (e.g., circulation).
Psychosociocultural Factors: Behavioral or cultural practices influencing hygiene and care.
Iatrogenic Factors: Conditions induced by medical treatment or diagnostic procedures.
Wound Healing Processes and Phases
Types of Wound Healing: * First Intention (Primary Intention): Characterized by a clean incision, as seen in surgical wounds. Uses early suturing to close edges. Results in a hairline scar. * Second Intention (Secondary Intention): Occurs with gaping, irregular wounds. Healing involves granulation tissue filling the gap. Epithelium eventually grows over the scar. * Third Intention (Delayed Primary Closure): Involves wounds that are left open initially to allow for drainage or infection control. Features increased granulation. Includes late suturing and typically results in a wide scar.
Phases of Wound Healing: * Inflammatory Phase: * Immediate response to injury. * Key features: Bleeding, formation of a blood clot, and the development of a scab. * Proliferative Phase: * Focuses on building new tissue. * Key components: Fibroblasts proliferating, macrophages cleaning the area, and the development of new blood vessels. * Remodeling (Maturation) Phase: * Final stage where tissue strengthens. * Features: Freshly healed epidermis and dermis layers.
Nursing Diagnosis and Assessment Frameworks
Core Nursing Diagnoses: * Risk for impaired skin integrity. * Impaired skin integrity. * Impaired tissue integrity.
Clinical Manifestations and Assessment Areas: * Types of skin lesions. * Types of wound healing. * Phases of wound healing. * Types of exudate (wound drainage).
Planning and Intervention: General Wound Care
Asepsis Standards: Differentiation between medical asepsis (clean technique) and surgical asepsis (sterile technique) based on the wound type.
Cleansing of Wounds: * Solutions: Use of isotonic saline ( sodium chloride) or specific wound cleansers. * Methods: Technique-specific protocols for irrigation or swabbing.
Wound Dressings Purposes: * Protection of the wound from external contaminants. * Maintenance of a moist wound environment to promote healing. * Absorption of excessive moisture/exudate.
Selected Dressing Types: * Gauze: Includes dry gauze, non-adherent gauze, and impregnated gauze. * Transparent Films: Allow for visualization and protection. * Hydrocolloid: Maintains moisture and provides a seal. * Hydrogels: Adds moisture to dry wounds. * Alginates: Highly absorbent dressings made from seaweed.
Procedure: Obtaining a Routine Wound Culture
Pain Management: Medicate the patient for pain if necessary prior to the procedure.
Preparation: Perform hand hygiene and assemble all required supplies.
Precautions: Strict adherence to standard precautions.
Cleansing: Cleanse the wound using normal saline before taking the culture.
Swabbing: Rotate a sterile swab back and forth specifically over a clean area of granulation tissue.
Processing: Place the swab into the culture medium without contaminating it and label the container immediately.
Transport: Place the specimen in a biohazard transport bag with the appropriate requisition form without contaminating the exterior of the bag.
Assessment of Risk: The Braden Scale
Total Scoring System: * The highest possible score is . * Score of or less: Patient is considered at risk. * Score of : Low risk. * Score of : Moderate risk. * Score of or less: High risk.
Six Assessment Categories: * Sensory Perception: Ability to respond meaningfully to pressure-related discomfort. * 1: Completely Limited (unresponsive to pain). * 2: Very Limited (responds only to pain). * 3: Slightly Limited (responds to verbal commands, can't always communicate discomfort). * 4: No Impairment. * Moisture: Degree to which skin is exposed to moisture. * 1: Constantly Moist. * 2: Very Moist. * 3: Occasionally Moist. * 4: Rarely Moist. * Activity: Degree of physical activity. * 1: Bedfast. * 2: Chairfast. * 3: Walks Occasionally. * 4: Walks Frequently. * Mobility: Ability to change and control body position. * 1: Completely Immobile. * 2: Very Limited. * 3: Slightly Limited. * 4: No Limitation. * Nutrition: Usual food intake pattern. * 1: Very Poor (rarely eats more than of food offered). * 2: Probably Inadequate. * 3: Adequate. * 4: Excellent. * Friction and Shear: * 1: Problem (requires moderate to max assistance in moving). * 2: Potential Problem. * 3: No Apparent Problem.
Pressure Injury Staging and Assessment
Stage 1: Non-blanchable erythema. The skin remains unbroken but is reddened and does not turn white when pressed.
Stage 2: Partial thickness skin loss. Involves the epidermis and potentially the dermis. Often presents as a blister or shallow crater.
Stage 3: Full thickness skin loss. Involves damage or necrosis of subcutaneous tissue, potentially down to the fascia. Usually characterized by drainage.
Stage 4: Full thickness skin loss with extensive tissue necrosis. Damage extends to muscle, bone, tendons, or joint capsules.
Unstageable: The base of the wound is obscured by eschar (black, necrotic tissue) or slough (yellow/tan tissue), making it impossible to determine the full depth.
Deep Tissue Injury (DTI): Intact skin that appears deep purple or maroon, indicating underlying damage (common on heels and hips).
Associated Conditions: * Undermining: Tissue destruction under the wound edges. * Tunneling: Narrow passages extending from the wound into deeper tissue.
Objective/Subjective Assessment Data: * Location and Size. * Color and Drainage. * Feel (Objective). * Sensation (Subjective). * Stage of Healing.
Treatment and Prevention Strategies
Treatment by Color Code: * Red: Goal is protection; use a protective cover. * Yellow: Goal is cleansing; remove debris using absorbent dressings and maintain a moist environment. * Black: Goal is debridement; remove necrotic tissue via surgical or enzymatic methods.
Technological Intervention: Pressure Ulcer with Wound Vac (Vacuum-Assisted Closure) System.
Prevention of Pressure Injuries: * Nutrition: Encourage food and fluid intake; assist with feedings. * Repositioning: Turn and position patients at a minimum of every (). Use turning schedules. * Off-loading: Elevate heels off the bed; use pillows to prevent knees and heels from rubbing. * Bed Positioning: Maintain Head of Bed (HOB) at an angle > 30^{\circ}. * Skin Care: Check and change incontinent patients promptly; limit the use of diapers; apply barrier sprays or creams. * Constant Monitoring: Check the skin every time the patient is changed, toileted, bathed, dressed, transferred, or turned.
Questions & Discussion
Q: During a dressing change the nurse assesses a reddish-pink tissue in the wound. The nurse interprets this is most likely indicating: * A: Granulation tissue.
Q: During a patient assessment, which would the nurse consider to be at high risk for a pressure injury? (Select all that apply) * A: 86 year old patient; postop hip surgery patient; patient unable to control their urine. (Note: These factors relate to age, mobility, and moisture).
Q: After assessment, the nurse documents the presence of a reddened area that has blistered. What stage is this injury? * A: Stage II.
Q: Which nursing intervention would be priority in preventing a patient from developing a pressure injury? * A: Providing frequent off-loading measures.
Q: The nurse is preparing to collect a wound culture. Which is a part of the preparation? * A: Check the HCP order to see the location of the prescribed culture. (Note: Analgesics should be given significantly before the procedure, typically minutes depending on the route, but not necessarily minutes if standard protocols differ, and definitely not only minutes).